University of Groningen Adverse events following cervical manual physical therapy techniques Kranenburg, Hendrikus

Adverse events following cervical manual physical therapy techniques

Kranenburg, Hendrikus

DOI:

10.33612/diss.108344065

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2019

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Citation for published version (APA):

Kranenburg, H. (2019). Adverse events following cervical manual physical therapy techniques.

Rijksuniversiteit Groningen. https://doi.org/10.33612/diss.108344065

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Financial support for the printing of this thesis by the following sponsors is gratefully acknowledged:

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• University of Groningen

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Adverse events following cervical

manual physical therapy techniques

Proefschrift

ter verkrijging van de graad van doctor aan de

Rijksuniversiteit Groningen

op gezag van de

rector magnificus prof. dr. C. Wijmenga

en volgens besluit van het College voor Promoties.

De openbare verdediging zal plaatsvinden op

woensdag 8 januari 2020 om 16.15 uur

door

Hendrikus Antonius Kranenburg

geboren op 2 augustus 1980

te Ermelo

Kranenburg_Rik_Binnenwerk_V3.indd 3

Prof. dr. C.P. van der Schans

Copromotores

Beoordelingscommissie

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Jappe Scherpbier Baudina Visser

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Chapter 1 General introduction 8

Chapter 2 Beliefs and the use of spinal thrust joint manipulation: a

survey of Dutch manual physical therapists 22

Submitted

Chapter 3 Adverse events following cervical manipulative therapy:

consensus on classification among Dutch medical specialists, manual therapists, and patients

42

Published in: Journal of Manual and Manipulative Therapy, 2017; 25;(5);279-287

Chapter 4 Adverse events associated with the use of cervical spine

manipulation or mobilization and patient characteristics: A systematic review

72

Published in: Manual Therapy, 2017; 28; 32-38

Response letter to: Adverse events associated with the use of cervical spine manipulation or mobilization and patient characteristics: A systematic review

112

Published in: Musculoskeletal Science and Practice, 2018; 30; e95

Chapter 5 Carotid and vertebral arterial dissections after manual

physical therapy: a case control study 116

Submitted

Chapter 6 Effects of head and neck positions on blood flow in the

vertebral, internal carotid, and intracranial arteries: A systematic review

132

Published in: JOSPT, 2019; 5; 1-59

Chapter 7 Adverse events after cervical manipulative therapy: A

prospective cohort study 184

Submitted

Chapter 8 Summary 204

General discussion 209

Nederlandse samenvatting 212

Dankwoord 217

Research Institute SHARE 220

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INTRODUCTION

Manual physical therapy is considered an effective intervention for non-specific neck pain and neck-related headache. However, there is a debate in literature and amongst clinicians about the use of these therapeutic interventions in relation to the risk of complications following manual physical therapy. Within the process of clinical reasoning, manual physical therapists (and other professionals who apply manual therapy intervention to the cervical spine) should weigh the expected benefit of the interventions in an individual patient against the risk of adverse events, the so-called risk-benefit ratio. Considerations of the risk-benefit ratio should be based on the knowledge of the effectiveness of these interventions, and on the risk and frequency of occurrence, also known as the incidence, of adverse events following these interventions. Until now, there has been a lack of information about the incidence and characteristics of adverse events following manual physical therapy (and comparable interventions) applied to the cervical spine.

This introduction to the thesis will focus on the determinants of the risk-benefit ratio related to manual physical therapy interventions applied to the cervical and upper cervical spine. An oversight of literature concerning the characteristics of non-specific neck pain (and related headache), the epidemiology of non-specific neck pain (and related headache), and the effects of manual physical therapy will be described. Thereby, current knowledge of the characteristics and frequency of occurrence of adverse events (which knowledge is scarce) will be given. As manual physical therapy interventions are described in relation to adverse events, characteristics of these interventions are described too.

CHARACTERISTICS AND CLASSIFICATION OF NON-SPECIFIC NECK PAIN

Neck pain is a common and multimodal health problem that includes physical, affective, cognitive, and social aspects.(Blanpied et al., 2017; Hoy et al., 2014) Usually the cause of the neck pain is benign (99%).(Rubinstein et al., 2008) The patho-anatomical basis for neck pain is unknown in most patients and therefore characterized as nonspecific or mechanical.(de Vries et al., 2016) The most common used categories for neck pain are: 1] neck pain with mobility deficits; 2] with impaired movement coordination; 3] neck pain with headache; 4] neck pain with radiating pain; and 5] neck pain and migraine.(Blanpied et al., 2017; Gross et al., 2015; Hogg-Johnson et al., 2008; Jull and Hall, 2018) The exact relationship between neck pain and headache is unknown. However, the prevalence of neck pain is significantly higher in patients with migraine (76.2%) and tension type headache (88.4%) than in the general population (57.8%).(Ashina et al., 2015; Moore et al., 2017) The most

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used classifications for neck pain are by time, severity, symptoms or anatomical structures.(Bier et al., 2018; Blanpied et al., 2017; Guzman et al., 2009)

EPIDEMIOLOGY OF NON-SPECIFIC NECK PAIN

The incidence of neck pain is estimated varying from 14%-21%%, a point prevalence of 4.9%, and a 1 year prevalence ranging of 37.5%.(Blanpied et al., 2017; Fejer et al.,

2006; Hoy et al., 2014) With a 4th _{place for disability on the musculoskeletal burden}

of disease, the influence on daily life can be considered as severe.(Smith et al., 2014) In the Netherlands, It is the third musculoskeletal location for complaints and 40% of the total costs of spinal pain are thought to be due to neck pain.(Bier et al., 2018; Picavet and Schouten, 2003)

CHARACTERISTICS OF MANUAL PHYSICAL THERAPY INTERVENTIONS

Both neck pain and headache patients frequently seek help in primary care for a diagnosis and to relieve symptoms.(Blanpied et al., 2017; Gross et al., 2015; Moore et al., 2017) Treatments are often multimodal during which both hands-on and hands-off techniques are advised and used.(Bier et al., 2018; Blanpied et al., 2017) Hands-off techniques may consist of specific or general exercises, advice, postural corrections, cognitive behavioural therapy, and workplace interventions. Hands-on therapy may consist of cervical mobilizations, manipulations, neurodynamics, taping and massage therapy. Most of the advised techniques are based on low quality evidence. However, the combination of cervical mobilizations or manipulations and exercise therapy for neck pain patients Grade I or II is based on high quality evidence.(Bier et al., 2018; Blanpied et al., 2017)

Manipulations and mobilizations are both hands-on techniques. Although the terms might seem alike, they are interchanged in literature and are often deployed for the same indications or outcomes, they are significantly different.(Mintken et al., 2008; Rushton et al., 2016, p. 31) In their educational standards document, the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) has defined a manipulation as: “A passive, high velocity, low amplitude thrust applied to a joint complex within its anatomical limit with the intent to restore optimal motion, function, and/or to reduce pain.” Following the same document a mobilization is defined as: “A manual therapy technique comprising a continuum of skilled passive movements that are applied at varying speeds and amplitudes to joints, muscles or nerves with the intent to restore optimal motion, function, and/or to reduce pain.”(Rushton et al., 2016, pp. 31–32) The key difference between those two techniques is the high velocity impulse with which a manipulation is applied. Furthermore, a manipulation is applied towards the end

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of the anatomical limit of a joint, whereas a mobilization can be applied in an end range position as well as in the range before that anatomical limit.

BENEFITS OF MANUAL PHYSICAL THERAPY

The possible benefits of treatment modalities which are weighed against the possible risks are an essential component of the complex and multimodal clinical reasoning process of a manual physical therapist.(Rushton et al., 2016) Cervical manipulations seem more effective for neck pain than thoracic manipulations and demonstrated fewer side effects.(Puentedura et al., 2011) The effectiveness of cervical techniques, including manipulations and mobilizations, has been described in a Cochrane review.(Gross et al., 2015) This review, including 51 trials with 2920 participants, showed that manipulations seemed not to be more effective than mobilizations at an immediate, short term and intermediate follow-up. However, multiple sessions with cervical manipulations led to more pain relief and functional improvement than pain medication at immediate, short, intermediate and long follow-up. Effect sizes described in Standard Mean Differences (SMD) were reported for pain between -0.19 and -0.34 favoring multiple cervical manipulations versus medication. When comparing cervical manipulations versus cervical mobilizations the pooled SMD for pain was -0.07 favoring manipulation and the SMD for function and disability scored between 0.10 and -1.71. Differences in execution of manual techniques could also lead to differences in effectiveness.(Gross et al., 2015) A combination of manual techniques and exercise is recommended.(Bier et al., 2018) RISKS OF MANUAL PHYSICAL THERAPY

The World Health Organization considers cervical manipulations or mobilizations performed by chiropractors as safe and effective treatment which carries the risk of few mild and transient adverse events.(World Health Organization, 2015) Most of those risks concern minor or moderate adverse events.(Cagnie et al., 2004; Chaibi and Russell, 2019; Sweeney and Doody, 2010) Although it can be hard to classify adverse events, they can be classified as not adverse, minor, moderate and major adverse. (Carnes et al., 2010) ‘Major’ adverse events are defined as medium to long term, moderate to severe and unacceptable, they normally require further treatment and are serious and distressing; ‘Moderate’ adverse events are as ‘major’ adverse events but only moderate in severity; and ‘Mild’ and ‘not adverse’ adverse events are short term and mild, non-serious, the patient’s function remains intact, and they are transient/reversible; no treatment alterations are required because the consequences are short term and contained.(Carnes et al., 2010) Classification can be difficult without a context or details and there is a possible overlap between

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categories in the classification as described by Carnes.(Carnes et al., 2010) In particular, the category ‘moderate’ is difficult to work with in clinical practice and in research. The overlap between the minor and major categories is probably too large. (Carlesso et al., 2011) Furthermore, if the definitions used to categorize were linked to the international classification of diseases and Related Health Problems (ICD-10) and the international classification of functioning, disability and health (ICF), that would enhance clarity and simplify usage. (World Health Organisation, 2012, 2001) The incidence of major adverse events following manual therapy is of considerable interest and has only described anecdotally. However, incidences have been estimated ranging from 1:3.000 to 1:6.000.000.(Assendelft et al., 1996; Magarey et al., 2004; Nielsen et al., 2017) However, due to the severity of the consequence’s cases are repeatedly published and are abundantly covered by media. In most published cases a cervical manipulation was involved during the treatment session.(Ernst, 2007; Nielsen et al., 2017) The Heath and Youth Care Inspectorate in The Netherlands receives approximately two cases with major AE following manual physical therapy per year.(Pool, 2019) However, the frequency with which manipulations and mobilizations are applied is unknown in The Netherlands. The absence of representable incidence rates makes it difficult to place those adverse events in perspective. Particularly since causality has not been established, discussions remain intense on whether or not to use these techniques and which precautions should be considered.(Cassidy et al., 2012; Church et al., 2016; Wand et al., 2012) To assist the clinician in this clinical reasoning process and physical assessment the IFOMPT has developed a framework which has also generated discussion.(Kerry et al., 2014; Rushton et al., 2014; Scholten-Peeters et al., 2014) Since most of the adverse events following cervical manipulations seem of a neurovascular origin the framework focusses on cervical artery dysfunctions.(Biller et al., 2014)

CERVICAL ARTERIAL DISSECTION

Cervical arterial dissections arise when the inner wall of an artery (tunica intima) of the outer adventitia layer ruptures and creating a false lumen.(Blum and Yaghi, 2015) This may narrow or even close the lumen of the artery. Also, it can create a secondary blood flow in the false lumen, resulting in a thrombus which can cause a stoke. Cervical arterial dissections can occur in the internal carotid arteries and in the vertebral arteries. (Figure 1) The internal carotid arteries are also known as the anterior circulation because they supply the anterior part of the brain with blood. The vertebral arteries are often referred to as the posterior circulation because the supply the posterior part of the brain with blood. Fortunately, mortality rates of

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cervical dissections are low (4%) and functional outcomes are usually good.(Debette, 2014) The pathophysiology of cervical dissection is multifaceted and not yet fully understood.(Debette, 2014; Hutting et al., 2018; Thomas, 2016) The incidence rate for a spontaneous carotid artery dissection is 2.3-3.0 per 100.000 people and for the vertebral artery 1.0-1.3 per 100.000 people and should be taken into account when calculating an increased risk after cervical techniques.(Debette et al., 2009; Dziewas et al., 2003; Schievink et al., 1994) Although no causal relationship between cervical manipulations and cervical dissections has been established, an association has been suggested.(Cassidy et al., 2017, 2008) A cervical artery dissection can be caused by intrinsic and extrinsic factors.(Debette, 2014; Thomas, 2016) Intrinsic factors may be an underlying arterial pathology, anomaly or a genetic predisposition. (Debette et al., 2009; Thomas, 2016) Infections or cervical traumata such as motor vehicle accidents are considered extrinsic factors. It is unlikely that a cervical manipulation will damage a healthy arterial wall. However, in extremely rare cases, when a cervical arterial dissection is already present, it cannot be disregarded that cervical manipulation is such an extrinsic factor.(Eriksen et al., 2011) It has also been suggested that the manipulation may trigger an embolus or a vasospasm or that the manipulative position might alter blood flow.(Haldeman et al., 1999; Mann and Refshauge, 2001; Mitchell, 2009) However, the latter explanation is challenged by the anatomical disposition via the circle of Willis. Furthermore, it would also mean that the technique itself is secondary to the treatment position which is contrary to the reported cases of major adverse events. Moreover, it would be in contrast to the suggestion that mobilizations are of ten presented as a safer alternative to manipulations.(Gross et al., 2015) Especially since cervical manipulations are typically performed in a mid-range

Figure 1. Cervical arteries

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position while mobilizations are regularly performed in an end-range position. (Dunning et al., 2016; Reid et al., 2014)

Cervical arterial dissections usually present with local pain, ipsilateral neck pain, ipsilateral headache and a Horner syndrome and this typical pattern is only existent in less than one-third of patients. Diagnosis is regularly overlooked for some time precisely because of the lack of specific signs.(Thanvi et al., 2005) Usually, unilateral neck pain or headache have a musculoskeletal origin and are benign. Unfortunately, these arterial symptoms can mimic the musculoskeletal complaints when other neurological symptoms are absent. Especially, for the carotid artery dissection differentiation can be difficult. (Debette et al., 2009; Thomas, 2016) However, cervical arterial dissection patients frequently label their symptoms as being different to those experienced before or as abnormal.(Debette et al., 2009) Besides an MRI T1 with fat suppression, a comprehensive patient history seems essential to identify patients at risk.(Debette et al., 2009; Puentedura et al., 2012; Rushton et al., 2014; Thomas, 2016) Especially because pre-manipulative arterial tests seem to have a low diagnostic accuracy, a low pretest probability and can even be harmful for the patient.(Hutting et al., 2018, 2013)

AIM OF THIS THESIS

There is a need to gain clarity on patient and treatment characteristics that can predict adverse events following manual physical therapy and data to put the adverse events in perspective. Therefore, the three aims of this thesis are:

1] To identify patients which are more at risk for AE following manual physical therapy by identifying and understanding risk factors within the patient, therapist and the techniques used during treatment.

In chapter two, the purpose is to gain a general insight in spinal care in manual

physical therapy practices so a perspective can be formed. This will be achieved by quantifying the amount of manipulations per spinal region during treatments in clinic, by determining thoughts of clinicians on safety and efficacy about the application of manipulations and inventory their clinical decision making. The

purpose of chapter four is to systematically review the literature to identify the

characteristics of 1) patients, 2) practitioners, 3) treatment process and 4) adverse

events (AE) occurring after cervical manipulation or cervical mobilization. In chapter

five, the purpose is to explore differences between hospitalized CeAD patients and

controls receiving a cervical manipulation in clinical practice by means of a

case-control study. The purpose of chapter six is to determine, the effects of

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cervical positions and movements on hemodynamic parameters (blood flow velocity and/or volume) of cervical and cranio- cervical arteries.

2] To develop a classification system that is suitable for clinical practice and research by which AE can be reported.

The aim of chapter three is to develop a classification system for adverse events that

is useful for research and practice, including patients and clinicians’ perspectives, has an acceptable number of categories and clear definitions, and is based on the international classification diseases and Related Health Problems (ICD-10) and the international classification of functioning, disability and health (ICF).

3] To collect the frequency with which techniques are used and the frequency with which adverse events are reported to put the AE in perspective.

In chapter seven, purpose is to determine the number, type and predictors of AE

following cervical treatments performed by Dutch manipulative therapists.

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Pool, J., 2019. Ernstige complicaties na cervicale manipulatie. Casuistiek- twee incidenten, gemeld bij de Inspectie Gezondheidszorg en Jeugd. FysioPraxis 28, 32–35.

Puentedura, E.J., Landers, M.R., Cleland, J.A., Mintken, P., Huijbregts, P., Fernandez-De-Las-Peñas, C., 2011. Thoracic Spine Thrust Manipulation Versus Cervical Spine Thrust Manipulation in Patients With Acute Neck Pain : A Randomized Clinical Trial. J. Orthop. Sport. Phys. Ther. 41, 208–220. https://doi.org/10.2519/jospt.2011.3640

Puentedura, E.J., March, J., Anders, J., Perez, A., Landers, M.R., et al., 2012. Safety of cervical spine manipulation: are adverse events preventable and are manipulations being performed appropriately? A review of 134 case reports. J Man Manip Ther 20, 66–74. https://doi.org/10.1179/2042618611Y.0000000022

Reid, S.A., Rivett, D.A., Katekar, M.G., Callister, R., 2014. Comparison of Mulligan Sustained Natural Apophyseal Glides and Maitland Mobilizations for Treatment of Cervicogenic Dizziness: A Randomized Controlled Trial. Phys. Ther. 94, 466–476. https://doi.org/10.2522/ ptj.20120483

Rubinstein, S.M., Knol, D.L., Leboeuf-Yde, C., van Tulder, M.W., 2008. Benign Adverse Events Following Chiropractic Care for Neck Pain Are Associated With Worse Short-term Outcomes but Not Worse Outcomes at Three Months. Spine (Phila. Pa. 1976). 33, E950– E956. https://doi.org/10.1097/BRS.0b013e3181891737

Rushton, A., Beeton, K., Ronel, D., Mr, J., Langendoen, J., Lenerdene, M., Mrs, L., Maffey, L., Pool, J., 2016. IFOMPT Standards Document.

Rushton, A., Rivett, D., Carlesso, L., Flynn, T., Hing, W., Kerry, R., 2014. International framework for examination of the cervical region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy intervention. Man. Ther. 19, 222–8. https://doi.org/10.1016/j. math.2013.11.005

Schievink, W.I., Mokri, B., Piepgras, D.G., 1994. Spontaneous dissections of cervicocephalic arteries in childhood and adolescence. Neurology 44, 1607–1612. https://doi.org/10.1212/ WNL.44.9.1607

Scholten-Peeters, G.G.M., van Trijffel, E., Hutting, N., Castien, R.F., Rooker, S., Verhagen, A.P., 2014. Risk reduction of serious complications from manual therapy: Are we reducing the risk?. Correspondence to: International Framework for Examination of the Cervical Region for Potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy In. Man. Ther. 19, e5–e6. https://doi.org/10.1016/j.math.2014.01.007

Smith, E.U.R.R., Hoy, D.G., Cross, M.J., Sanchez-Riera, L., Blyth, F., et al., 2014. Burden of disability due to musculoskeletal (MSK) disorders. Best Pract. Res. Clin. Rheumatol. 28, 353–366. https://doi.org/10.1016/j.berh.2014.08.002

Sweeney, A., Doody, C., 2010. Manual therapy for the cervical spine and reported adverse effects: A survey of Irish Manipulative Physiotherapists. Man. Ther. 15, 32–36. https://doi. org/10.1016/j.math.2009.05.007

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Thanvi, B., Munshi, S.K., Dawson, S.L., Robinson, T.G., 2005. Carotid and vertebral artery dissection syndromes. Postgrad. Med. J. https://doi.org/10.1136/pgmj.2003.016774 Thomas, L.C., 2016. Cervical arterial dissection: An overview and implications for manipulative

therapy practice. Man. Ther. 21, 2–9. https://doi.org/10.1016/j.math.2015.07.008 Tuchin, P., 2017. Letter to the editor - Adverse events associated with the use of cervical spine

manipulation or mobilization and patient characteristics. Musculoskelet. Sci. Pract. 30, e93–e94. https://doi.org/10.1016/j.msksp.2017.05.006

Wand, B.M., Heine, P.J., O’Connell, N.E., 2012. Should we abandon cervical spine manipulation for mechanical neck pain? Yes. BMJ 344, e3679. https://doi.org/10.1136/bmj.e3679 World Health Organisation, 2012. International Classification of Diseases (ICD-10) [WWW

Document]. WHO. https://doi.org/10.1177/1071100715600286

World Health Organisation, 2001. International Classification of Functioning, Disability and Health (ICF) [WWW Document]. WHO. URL http://apps.who.int/classifications/icfbrowser/ World Health Organization, 2015. WHO guidelines on patient safety [WWW Document]. WHO.

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H.A. Kranenburg, E.J, Puentedura, M.A. Schmitt, C.P. van der Schans, N.R. Heneghan, N. Hutting

THRUST JOINT MANIPULATION:

A SURVEY OF DUTCH MANUAL

PHYSICAL THERAPISTS

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ABSTRACT

Introduction: Thrust Joint Manipulation (TJM) is a widely used intervention in spinal care, however there are differences in its use between countries and spinal regions. The aim of this survey study was to quantify the amount of TJM used within the spinal regions among Dutch certified manual physical therapists, their thoughts regarding safety and efficacy related to the application of TJM techniques.

Method: The 19-question e-survey was based on a similar survey in the USA. Since the Netherlands has a separate professional standard for the upper cervical spine, questions enabled differentiation between upper- and mid/lower cervical spine. The survey was launched during a national manual therapy congress and distributed via social media (April-July 2018). Descriptive analysis, MANOVA and qualitatively analyses were used.

Results: From the 211 responses, 150 were male, with a mean age of 44.9 (±11.2), a mean clinical experience of 12.8 years (±9.6) as manual physical therapist, 87% had a master’s degree and 97 % worked in a private practice. Except for the upper cervical spine, more than 80% of the participants felt that TJM was safe, were comfortable performing TJM. Overall >80% performs additional screening prior to TJM. Concerns about safety is the greatest barrier for upper cervical TJM.

Discussion: Findings indicate that overall Dutch Manual Therapists believe TJM to be safe and effective and are comfortable performing them, except for the upper cervical spine, where concerns exist regarding safety and acquiring written informed consent.

Level of evidence: 2b

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INTRODUCTION

Thrust Joint Manipulation (TJM) is an intervention widely used by manual physical therapists, chiropractors and osteopaths, within a multimodal biopsychosocial approach to manage spinal complaints. TJM techniques are characterized as involving a specific high-velocity low amplitude thrust with the aim of achieving joint cavitation.(Puentedura et al., 2017) Evidence, including clinical guidelines supports TMJ for all spinal regions for improving patient-reported outcomes, and performance-based outcomes.(Bier et al., 2018; Blanpied et al., 2017; Cross et al., 2011; de Campos, 2017; Gross et al., 2015; Michaleff et al., 2012) Although recommended, TJM techniques have been linked with serious adverse events and unwanted side-effects.(Church et al., 2016; Hebert et al., 2015; Kranenburg et al., 2017; Nielsen et al., 2017; Puentedura et al., 2012; Puentedura and O’Grady, 2015; Thoomes-de Graaf et al., 2017) Serious adverse events are mostly reported for the cervical spine and may be major with consequences such as spinal cord injury or stroke, especially related to TJM in the cervical and upper cervical spine.(Cagnie et al., 2004; Puentedura et al., 2012) Unwanted side-effects are more common and involve onset of new symptoms or a temporary worsening of symptoms for only 24 to 48 hours. Adverse events and unwanted side-effects may lead clinicians to limit their use of TJM or perhaps even abandon.(Carlesso et al., 2010; Puentedura et al., 2017)

A recent U.S. survey investigated physical therapist (PT) utilization, comfort and perceptions about TJM.(Puentedura et al., 2017) Pre-thrust examination to prevent adverse events and unwanted side-effects was performed most often in the cervical spine. PT’s reported being most comfortable with TJM in the thoracic, less so in the lumbar and least in the cervical spine. Most of the barriers to use TJM in U.S. involved fear / lack of confidence or a lack of education.(Puentedura et al., 2017) Thoracic spine TJM was considered the most safe and effective, followed by the lumbar spine and cervical spine.(Puentedura et al., 2017) PTs appear to be less comfortable and less confident in the cervical spine region whilst it is also the region reported to be most susceptible to adverse events during their training.(Thoomes-de Graaf et al., 2017)

In the Netherlands, clinical practice differs from the U.S in several ways. Firstly, slightly more than 50% of all patients in private practice enter healthcare via direct access.(NIVEL, 2016) Secondly, TJM is not included in the entry-level Bachelor of Physical Therapy program, but is instead, taught in a three-year manual therapy master’s program (fulfilling IFOMPT Educational Standards). After this, a Dutch

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PT becomes certified as a manual therapist. All certified manual therapists are registered in a quality register. However, there are also non-certified professionals who use TJM techniques having learned such skills in short professional courses. Thirdly, for the application of upper cervical spine (C0-C3) TJM techniques, a professional standard exists. This professional standard was developed by the Dutch Manual Therapy Association and is based on the IFOMPT Cervical Artery Dysfunction Framework.(Rushton et al., 2014) It comprises components of medical history, pre-manipulative examination and written informed consent.(Rushton et al., 2014)

The aim of this survey was to quantify the amount of TJM used within the lumbar, thoracic, mid/ lower cervical (C3-C7) and upper cervical (C0-C3) regions among Dutch certified manual physical therapists, and to determine their thoughts about safety and efficacy related to the application of TJM techniques and their clinical decision making. This study sought to contribute to the discussion concerning safety and efficacy of spinal TJM.

METHODS

A digital survey was developed using the Enalyzer software package specifically for IFOMPT members in the Dutch manual physical therapy setting.(“Enalyzer,” 2018) Previous surveys’ in the U.S. (Puentedura et al., 2017) and U.K. (Heneghan et al., 2018) were used to inform the development of the survey. The study is reported in line with the Checklist for Reporting Results of Internet Surveys (CHERRIES). (Eysenbach, 2004)

SURVEY DEVELOPMENT

The survey of Puentedura et al. (Puentedura et al., 2017) was translated and adapted (HAK) into the Dutch setting with a separate standard for the upper cervical spine. The survey was piloted and revised by two native Dutch expert manual therapists with extensive experience in orthopedic PT education and research (NH and MS). Key differences between the Dutch and U.S. survey related to therapist certifications and differentiation of practice for TJM for the upper (C0-C3) and mid / lower cervical spine (C3-C7) regions.

A brief description of the content and the aim of the survey was provided. Most questions were closed questions with an option for additional text for responses to questions where ‘other’ was provided. The survey contained questions about gender, age, level of education, other relevant courses, experience as a PT,

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experience as a manual therapist, work setting, estimated percentage of patients with complaints for each spinal region, and whether the respondent was aware of any of the clinical prediction rules for TJM. (Questions 1-10) Next, the participants were asked for their opinions on the following areas: 1] beliefs about the safety of TJM for each of the spinal regions (Question 11); 2] pre-thrust examination for each spinal region (Question 12); 3] use of TMJ for each spinal region (Question 13); 4] their level of comfort performing TMJ for each spinal region (Question 14); and 5] possible barriers to performing TJM for each spinal region (Questions 15-18). Content validity was strengthened using Puentedura’s publication and the clinical expert opinions (HAK, MS, NH and NHe.(Puentedura et al., 2017)

The survey was piloted by four Dutch manual therapists who gave feedback on wording, clarification of response choices and the estimated duration.

For all respondents, all questions were presented in the same order and all questions were mandatory for survey completion. If respondents answered that they were not aware of any clinical prediction rules, they were not asked to clarify which ones. For the last four questions respondents could, next to the predefined answers choose an ‘other’ option in which they could specify barriers.

SETTING AND RECRUITMENT

The link to the survey was presented at the annual national manual therapy conference in the Netherlands on April 7, 2018, posted on the website of the Dutch Association for Manual Therapy (NVMT), distributed via social media (Twitter, Facebook and LinkedIn) and word of mouth. The survey was open until July 31, 2018. To optimize the response rate, reminders were posted on social media and published on the NVMT website and once in the NVMT news mail.

A priori, sample size was calculated using the formula as suggested by Dillman for e-surveys.(Dillman, 2007)

In this formula, Ns = completed sample size for desired level of precision, Np = size of population, p = proportion of population expected to choose one of the two

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response categories, B  =  acceptable amount of sampling error, C  =  Z statistic associated with the confidence level.

For this study, the number of registered MPT’s fulfilling the IFOMPT educational standards in Netherlands was 4500 as of October 2018.(Koninklijk Nederlands Genootschap voor Fysiotherapie (KNGF), 2018) The proportion of the population (p) expected to choose one of the two response categories (to participate or not) was set at 50/50 or 0.5. For the sampling error, 0.05 was set as acceptable with a confidence level of 90% and a corresponding Z-statistics of 1.645. This resulted in a required sample size (Ns) of 256 persons.

DATA PROCESSING AND ANALYSIS

Data of completed surveys was exported to Microsoft Excel (2016) and imported to IBM SPSS version 23 for statistical analysis. For the demographic data, descriptive analyses (frequencies, mean and standard deviation (SD)) were used. Frequencies and percentages are presented for closed questions, in tables or graphical bars. The four statements that surveyed the beliefs about TJM were analyzed with a related samples Friedman’s two-way analysis of variance by ranks, to explore the differences in thoughts about safety and effectiveness across spinal level. The level of significance was set at <0.05. Significant values were adjusted by the Bonferroni correction for multiple tests. The four statements were analyzed for differences in clinical experience using MANOVA. The open answers were analyzed qualitatively in order to look for specific ‘themes’ in barriers for each of the spinal regions. This was done by a posterior content analyses for ‘themes’ to be identified and quantified with calculation of frequencies for each category by 2 researchers (HAK and MS). (Vaismoradi et al., 2013)

ETHICS

This study was deemed exempt by the Medical Ethical Committee of the University Medical Center Groningen, The Netherlands. At the start of the survey participants were informed that participation was voluntarily, and continuation assumed an informed consent. Participants were informed regarding the aim of the survey, the expected duration and assurance of participant anonymity.

RESULTS

In total, the survey was accessed 309 times, with 211 surveys completed, (68% (211 / 309)). A further 97 incomplete surveys were not included in the final analysis

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as inclusion of returns with missing data would introduce bias and affect overall findings.(Eysenbach, 2004)

DEMOGRAPHICS

Of the 211 complete responses, 150 were male (71.1%) with a mean age of 44.9 (SD11.2, range 26-67). The 61 participating females had a mean age of 39.4 (SD9.9, range 26-63). Details of ages, years of practice and level of education, and work setting are specified in Table 1.

ESTIMATED PERCENTAGE OF PATIENTS FOR EACH SPINAL REGION

To put the participants answers into perspective, they were asked to estimate the percentage of patients in their clinic for each spinal region. Patients with cervical complaints are seen most often (36%), followed by the lumbar region (35%), the thoracic spine (18%) and the pelvic region (11%).

AWARENESS OF CLINICAL PREDICTION RULES

Most respondents (80.6%) were aware of spinal clinical prediction rules related to TJM. Of the respondents that answered affirmative, 143 (84%) respondents knew clinical prediction rules about low back pain and lumbar manipulation; 121 (71.2%) respondents knew about the clinical prediction rules concerning neck pain and thoracic manipulation; and 142 (83.5%) knew about clinical prediction rules for neck pain and cervical manipulation.

UTILIZATION OF TJM

Friedman’s showed a significant difference between the regions. x2_{(3) = 285.268, p <}

0.000. Post hoc tests illustrated a significant difference between upper cervical and lumbar (p = 0.000), upper cervical and thoracic (p = 0.000), upper cervical and mid/ low cervical (p = 0.000), mid/ low cervical and thoracic (p = 0.000). There were no significant differences between any other regions. Over 90% of the therapists stated that TJM were most often performed in the thoracic spine and least frequently in the upper cervical spine (less than 50%) (FIGURE 1).

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Figure 1. Levels of agreement with the statement “I regularly provide Thrust Joint

Manipulation to the XXX spine where it is indicated.”

Friedman’s revealed signifi cant diff erences between upper cervical and lumbar (p = 0.000), upper cervical and thoracic (p = 0.000), upper cervical and mid/ low cervical (p = 0.000), mid/ low cervical and thoracic (p = 0.000).

SAFETY AND EFFECTIVENESS OF TJM BY SPINAL REGION.

A signifi cant diff erence in perceived safety and eff ectiveness was found across

spinal region (x2 _{(3) = 249.371, p < 0.000). Post hoc tests illustrated diff erences}

between upper cervical and mid/ low cervical (p = 0.000), upper cervical and thoracic (p = 0.000), upper cervical and lumbar (p = 0.000), mid/ low cervical and thoracic (p = 0.003). There were no signifi cant diff erences between any other regions. Respondents believed that TJM was most eff ective and safe in the thoracic spine, followed by the lumbar and the mid/ low cervical spine. The upper cervical spine was deemed least eff ective and safe for TJM (FIGURE 2).

Figure 2. Levels of agreement with the statement “Thrust Joint Manipulation in the

XXX spine is safe and eff ective for patients in which it is indicated.”

Friedman’s revealed signifi cant diff erences between upper cervical and mid/ low cervical (p = 0.000), upper cervical and thoracic (p = 0.000), upper cervical and lumbar (p = 0.000), mid/ low cervical and thoracic (p = 0.003).

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A signifi cant diff erence was found between the regions. x2 _{(3) = 144.578, p < 0.000.}

Post hoc tests demonstrated signifi cant diff erences between upper cervical and lumbar (p = 0.000), upper cervical and thoracic (p = 0.000), mid/ low cervical and lumbar (p  =  0.005), mid/ low cervical and thoracic (p  =  0.003). There were no signifi cant diff erences between any other regions. Respondents reported to screen the upper cervical spine more than the other regions. Still, 90.5% of the respondents would routinely perform additional screening to the mid/lower cervical spine. For the thoracic and lumbar spine this was less with 81% and 82%, respectively (FIGURE 3).

Figure 3. Levels of agreement with the statement “Prior to performing Thrust Joint

Manipulation to the XXX spine, I would routinely perform additional screening.”

Friedman’s revealed signifi cant diff erences between upper cervical and lumbar (p = 0.000), upper cervical and thoracic (p = 0.000), mid/ low cervical and lumbar (p = 0.005), mid/ low cervical and thoracic (p = 0.003).

Comfort performing TJM by spinal region

A signifi cant diff erence was found between the regions. x2 _{(3) = 270.514, p < 0.000.}

Post hoc tests showed signifi cant diff erences between upper cervical and lumbar (p = 0.000), upper cervical and thoracic (p = 0.000), upper cervical and mid/ low cervical (p  =  0.000), mid/ low cervical and thoracic (p  =  0.009). There were no signifi cant diff erences between any other regions. Therapists agreed they were most comfortable performing TJM in the thoracic spine. Applying TJM to the upper cervical spine made therapists least comfortable (FIGURE 4).

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Figure 4. Levels of agreement with the statement “I am comfortable performing

Thrust Joint Manipulation to the XXX spine in patients that require it.”

Friedman’s revealed signifi cant diff erences between upper cervical and lumbar (p = 0.000), upper cervical and thoracic (p = 0.000), upper cervical and mid/ low cervical (p = 0.000), mid/ low cervical and thoracic (p = 0.009).

INFLUENCE OF CLINICAL EXPERIENCE

MANOVA showed no diff erences in the years of clinical experience in manual therapy for all four statements. Working experience did not seem to infl uence the respondent’s answers.

Statement: “I regularly provide Thrust Joint Manipulation to the XXX spine where it is indicated.” Wilks’ Lambda = .952, F=1.269, p=.258

Statement: “Thrust Joint Manipulation in the XXX spine is safe and eff ective for patients in which it is indicated.” Wilks’ Lambda = .967, F=0.852, p=.558

Statement: “Prior to performing Trust Joint Manipulation to the XXX spine, I would routinely perform additional screening.” Wilks’ Lambda = .984, F=0.419, p=.909 Statement: “I am comfortable performing Thrust Joint Manipulation to the XXX spine in patients that require it.” Wilks’ Lambda = .960, F=1.040, p=.405

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Percentage of respondents choices for provided options as well as ‘Other’ which then allowed for text entry.

The results that stand out most are the lack of barriers to perform thoracic TJM, the concerns about the safety of TJM for the upper cervical region and gaining informed consent for the upper cervical region. For the lumbar region: high pain score, pain in end range, arthrosis, pregnancy, hypermobile, pathology, age, co-morbidity, muscle control impairment, contraindications, medication, radicular syndrome and red fl ags were mentioned as ‘others’. For the thoracic spine: pregnancy, arthrosis, cancer, elderly, comorbidity, pathology, contraindications, medication, osteoporosis and internal organ projection. For the mid and lower cervical spine: Pregnancy, cancer, arthrosis, osteoporosis, pathology, elderly, comorbidity, contraindications, medication and red fl ags. Cancer, pregnancy, arterial disease, contraindications, medication and red fl ags were mentioned for the upper cervical spine.

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DISCUSSION

To our knowledge, this is the first study that has described the utilization of spinal TJM, perceptions of TJM safety and effectiveness, and perceived barriers to utilization of spinal TJM for Dutch manual therapists. Findings suggest that Dutch manual therapists generally believe TJM is a safe and effective treatment approach except for the upper cervical spine. They frequently apply TJM in the management of their patients. Dutch manual therapists feel comfortable performing TJM in the thoracic, lumbar, and to a lesser extent, in the lower-/ and mid cervical spine. Half of the respondents have doubts concerning the safety and effectiveness of TJM applied in the upper cervical spine. Therefore, utilization and comfort in performing upper cervical TJM differs considerably from other regions with several reported barriers being identified.

UTILIZATION AND BELIEFS ABOUT SAFETY OF TJM

The results of this study show that in the Netherlands, the cervical spine is the most often treated spinal region by manual therapists (36%). Respondents were most reserved to use TJM, were less confident, less comfortable and worried most about the safety of the TJM techniques in the cervical, compared with other regions. Differences between the upper cervical spine and the mid-/ lower cervical spine were notable with most respondents (69%) reporting concerns about safety as a barrier for the use of TJM in the upper cervical region, compared to just 43% in the mid-/ lower cervical spine. While 45.5% of the respondents completely agreed or somewhat agreed that TJM in the upper cervical spine were safe and effective, 90% of the respondents had the opinion that TJM in the mid-/ lower cervical spine were safe and effective.

CERVICAL SPINE

Only 45.5% of the respondents ‘somewhat agreed’ or ‘completely agreed’ that TJM in the upper cervical spine is a safe treatment technique, whilst 54.1% of the respondents are comfortable performing TJM in the upper cervical spine; perhaps attributable to inconclusive evidence of risk and benefit of the technique. (Kranenburg et al., 2017) It could also be that manual therapists find it difficult to acquire written informed consent when no other physical therapeutic intervention requires such consent in the Netherlands; 40% of the respondents perceived the written informed consent sheet as a barrier to performing upper cervical spine TJM. Our findings mirror a recent review of Australian manual therapists where reported negative perceptions like time constraints, evidence update necessary and raising unnecessary risk awareness as possible factors limiting the use of

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manual therapy.(Thomas et al., 2019) Although informed consent comprises ethical and legal components, there are different types of consent.(Rushton et al., 2014) Fundamentally, consent is integral to clinical reasoning and should be an ongoing process.(Rushton et al., 2014) The scope and nature of informed consent provided by each therapist in currently unknown.

THORACIC SPINE AND LUMBAR SPINE

More than half (52%) of the respondents experience no barriers for TJM in the thoracic region, and over 90% are comfortable performing TJM in that region. Although respondents are confident and often perform TJM in the thoracic region, 80.6% of the respondents would routinely perform additional screening prior to thoracic TJM, differing considerably to the reported data from the UK where this this is just 39.7% of respondents.(Heneghan et al., 2018) The content of the pre TJM examination is unknown. Whilst a detailed patient history underpins advanced clinical reasoning and selecting treatment interventions, advice for pre-manipulative testing remains unclear in the thoracic spine.(Heneghan et al., 2018; Puentedura and O’Grady, 2015) Similar results are seen in the lumbar spine, a considerable number of respondents are applying ‘additional screening’ of unknown content prior to lumbar TJM.

In the U.S., only 33% of the physical therapists reported they regularly provided TJM to the cervical spine.(Puentedura et al., 2017) A difference in utilization of TJM was also found in the UK, where the use of TJM for C0/C1, C1/C2, and C2/3-C4-C5 significantly differed, compared to C5/C6-C7/T1, and thoracic and lumbar spine. In that study, the reported use of TJM at C0/C1 (24%) and C1/C2 (22%) was only half the reported use of TJM at C2/C3 (66%), and only one third of the use of TJM at C5/C5-C7-T1 (80%).(Adams and Sim, 1998) The results from our survey differ from the results of the study conducted in the U.S. For the lumbar spine, in the U.S. 52.9% regularly provide TJM (Puentedura et al., 2017), while in the Netherlands this percentage is 86.2%. In the Netherlands, TJM for the thoracic spine is more frequently used (93.3%) than in the U.S (66.5%).(Puentedura et al., 2017) This difference may be due to the fact that we surveyed only manual physical therapists whereas in the U.S. study, Puentedura et al. (Puentedura et al., 2017) surveyed all licensed physical therapists regardless of their practice setting. In the U.K., Adams and Sim found rates for the lower cervical region of 80% -, 66% for the middle cervical,- 22-24% for the upper cervical-, 97% for the lumbar-, and 92% for the thoracic spine. (Adams and Sim, 1998)

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ADVANCED TRAINING

Respondents of our survey were Dutch manual therapists, who had completed a 3-year post-entry-level master’s degree in PT. Whereas in the U.S. study, all physical therapists were surveyed. Advanced training can influence the reasoning, decision making and skills of therapists. Nonetheless, advanced training also comprises critical reasoning and knowledge of the IFOMPT educational standards about possible risks that may occur.(Rushton et al., 2014)

STRENGTHS AND LIMITATIONS

A strength of this study is that it was based on a comparable survey.(Puentedura et al., 2017) Because we also surveyed barriers for each separate spinal region, this study provides an insight into the barriers for each spinal region as well. Results were analyzed for differences influenced by years of respondents’ clinical experience. This study has some limitations. Completion of the survey did not require a login so individuals could respond using multiple devices. Findings are subject to selection bias, with launch being at the annual National manual therapy conference (approximately 500 participants), posted on the website of the Dutch Association for Manual Therapy (approximately 2000 members), distributed via social media (Twitter, Facebook and LinkedIn) and word of mouth by the researchers in their network. In addition, the respondents of which 211 fully completed surveys, represented approximately 5% of the registered Dutch manual therapists, limiting the generalizability of findings

IMPLICATIONS FOR CLINICAL PRACTICE

Notwithstanding the limitations, study findings emphasize the importance of contemporary clinical practice of Dutch manual therapy being founded on current evidence of the risks and benefits of upper cervical spine versus low/ middle cervical spine TJM. Theoretically, it is possible that Dutch manual therapists might be overcautious regarding performance of TJM in the upper cervical spine. If the associated risk or contributing factor to cervical artery dysfunction is the manipulative position, then arguably this then also applies to mid/ lower cervical spine and upper thoracic spine TJM and not just for the upper cervical spine. Currently there appears insufficient evidence to support differentiating practice across some spinal regions. Whilst the occurrence of adverse events following TJM is rare, practitioners should however remain alert to the risks of TJM in the lower cervical and thoracic spine.

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FUTURE RESEARCH

Qualitative or mixed methods research could be helpful to explore the process and nature of consent in manual therapy, investigate the experiences with gaining pre-manipulative informed consent, and to identify whether barriers might lead to the use of TJM without such written informed consent. Furthermore, it might be of value to explore the various options for obtaining a more standardized informed consent.

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CONCLUSION

Findings suggest Dutch manual therapists are comfortable and confident in using TJM in the spine. Excluding the upper cervical spine, respondents feel that TJM’s are safe to use. Consequently, most barriers for the use of TJM were reported for the upper cervical spine and comprised concerns about safety.

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REFERENCES

Adams, G., Sim, J., 1998. A survey of UK manual therapists’ practice of and attitudes towards manipulation and its complications. Physiother. Res. Int. 3, 206–227. https://doi. org/10.1002/pri.141

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H.A. Kranenburg, S.E. Lakke, M.A. Schmitt & C.P. van der Schans

CERVICAL MANIPULATIVE THERAPY:

CONSENSUS ON CLASSIFICATION

AMONG DUTCH MEDICAL SPECIALISTS,

MANUAL THERAPISTS, AND PATIENTS

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